Gluteal Considerations for Patellofemoral Pain

Original Editor - Jacquie Kieck based on the course by Claire Robertson
Top Contributors - Jacquie Kieck, Wanda van Niekerk, Jess Bell and Tarina van der Stockt

Introduction[edit | edit source]

Patella malalignment is influenced not only by the patella, but also by the position of the femur and trochlear. The position of the femur and trochlear is altered by the gluteal muscles, hence the need to assess the gluteal muscles when considering patellofemoral pain[1][2]. The clinician should be cognisant that the assessment of the gluteal muscles in patellofemoral pain is not performed in isolation. Patellofemoral pain should be assessed holistically, considering various factors, including local factors around the knee, whole limb assessment and psychosocial factors[3] such as fear of movement and pain catastrophisation[4].

Why Do We Need to Consider Each Muscle?[edit | edit source]

Understanding the gluteal muscle's function in each plane of movement is imperative for accurately assessing the performance of this muscle group and it's influence on patellofemoral pain. When the clinician can specifically identify the plane of movement in which the dysfunction occurs, as well as isolate the problematic structure, targeted rehabilitation exercises can be prescribed.

Functional Role of the Gluteal Muscles[edit | edit source]

Gluteus Medius as an Abductor in the Frontal Plane[edit | edit source]

Gluteus medius acts as an abductor of the hip in the frontal plane. Poor hip abduction control in a single-stance, weight-bearing position allows for contralateral pelvis drop. In this scenario, the weight-bearing limb essentially falls into adduction, causing a functional valgus at the knee. This in turn creates greater load on the lateral patellofemoral joint (PFJ)[5].

Chart Illustrating the Impact of Poor Gluteus Medius Control on Patellofemoral Pain

Gluteus medius is assessed in the frontal plane by performing hip abduction against resistance. A recommendation is to perform the test by maintaining the resistance against hip abduction for 10 seconds. By sustaining the resistance to the muscle, it ensures that the tonic performance of the muscle is assessed (and not the phasic performance of the muscle which would be what is assessed in the first couple of seconds of holding the position against resistance). This is important because gluteus medius should act as a postural endurance muscle to stabilise the pelvis.

Assessment of the gluteus medius can also be performed in a weight-bearing position assessing the ability of the person to control the pelvis as they perform a contralateral hip drop when standing on a step. This position allows for concentric and eccentric assessment of the gluteus medius function. This position is also effective for strengthening of the gluteus medius[6].

Gluteus Medius as an External Rotator in the Horizontal Plane[edit | edit source]

The posterior fibres of gluteus medius are active as the primary external rotator of the hip at 0º to 20º of hip flexion. From 20º to 50º of hip flexion, the posterior fibres of gluteus medius are still active. Above 50º of hip flexion the gluteus maximus is the primary external rotator. To test the gluteus medius, resistance must be given against hip external rotation when the hip is in 0º to 20º of flexion.

Hip Flexion 0º - 20º 20º - 50º >50º
Primary external rotator of the hip Gluteus Medius Gluteus Medius is still active Gluteus Maximus

Gluteus Maximus as an External Rotator in the Horizontal Plane[edit | edit source]

Gluteus maximus externally rotates the hip when the hip is flexed. Testing of the gluteus maximus should be performed by providing resistance against external rotation of the hip when the hip is flexed. It is recommended to sustain the hold against external rotation, in this position, for ten seconds to test the tonic action of the muscle.

Rehabilitation Exercises[edit | edit source]

Gluteus Medius in the Frontal Plane (Hip Abduction)[edit | edit source]

Hip Abduction in Standing
Hip Abduction Against Resistance in Standing
Hip Abduction in Sidelying

Gluteus Medius in the Horizontal Plane (Hip Lateral Rotation at <20º of Hip Flexion)[edit | edit source]

External Rotation of the Hip in Standing
External Rotation of the Hip in Shallow Hip Flexion

Gluteus Maximus in the Horizontal Plane (Hip Lateral Rotation at >50º of Hip Flexion)[edit | edit source]

External Rotation of the Hip in 90º Hip Flexion
External Rotation of the Hip in 90º Hip Flexion/Sitting

Consider the Bridge Exercise[edit | edit source]

At the beginning of the bridge exercise, the hip is in deep hip flexion. This means that the gluteus maximus is most active as an external rotator of the hip. As the hip moves out of hip flexion into a more neutral position, gluteus maximus continues to work as a hip extensor, but the posterior fibres of gluteus medius become more prominent as a rotator.

Suggestions for progression of the bridge exercise, to make it more challenging, would be to lift the unaffected leg e.g. perform a one-legged bridge. Another alternative would be to add a weight placed on the person's abdomen.

Functional Role with Different Activities[edit | edit source]

Gait[edit | edit source]

During gait, gluteus maximus works eccentrically to control rotation at the hip[7]. After heel strike, about 24% into weight bearing, the femur and the tibia will internally rotate. This is to be expected, but should be for a short period only. Excessive internal rotation ultimately results in excessive loading of the lateral patellafemoral joint. Mirror gait retraining[8] has been shown to be effective for creating awareness of this for the patient and correcting the faulty biomechanics.

Running[edit | edit source]

Increased running speed is associated with increased movement in the frontal plane i.e. contralateral pelvis drop with corresponding hip adduction and resultant knee valgus, increasing the load on the lateral patellofemoral joint[9]. Bramah et al[10] demonstrated that for every 1° increase in pelvic drop during running, there was an 80% increase of being classified as injured. The same study by Bramah et al. showed that contralateral pelvis drop appeared to be the most strongly related variable to common running-related injuries, one of which being patellofemoral pain.

Video: Excessive hip adduction

[11]

When rehabilitating a patient with patellofemoral pain, where lack of control in the frontal plane is a contributing factor, it is useful to consider running speed. In an effort to reduce the load on the lateral patellofemoral joint, the clinician can suggest reducing running speed to offload the patellofemoral joint as an alternative to stopping sport altogether. In team sports a change of position on the court/field to a position where the patient will not be required to run as fast can be helpful[9].

Landing From a Jump[edit | edit source]

It has been shown that jump-landing kinematics are affected by lower limb injuries, including patellofemoral pain[12] as well as by gluteal muscle strength which influences dynamic knee valgus[13]. Similarly, a systematic review and meta-analysis by DeBleecker et al[12] showed some evidence for the association of impaired jump-landing kinematics and lower extremity overuse injuries. From the above it indicates that patello-femoral pain influences jump-landing kinematics, and that jump-landing kinematics is influenced by patello-femoral pain. Hence, it is important to assess jump-landing kinematics as a prevention strategy for lower extremity injuries such as patellofemoral pain as well as assessing jump-landing kinematics in a person suffering from a lower extremity injury such as patello-femoral pain. Psychosocial considerations such as kinesiophobia can be a consideration when assessing landing from a jump. For clients with patellofemoral pain participating in sports that require jumping, it is important to assess the jump-landing kinematics to identify poor gluteal control as a possible contributing factor.

Muscle Inhibition[edit | edit source]

A history of low back pain[2][14] or ankle injuries[15] have been shown to have an influence on gluteal function. Low back pain has been shown to inhibit gluteus maximus, and ankle inversion injuries are related to gluteus medius inhibition. The relevance of the gluteal muscles in patellofemoral joint pain has been clearly established. Given this relation, it is important to establish if the patient presenting with patellofemoral pain has a history of low back pain or ankle injury.

References[edit | edit source]

  1. Ireland ML, Willson JD, Ballantyne BT, Davis IM. Hip strength in females with and without patellofemoral pain. Journal of orthopaedic & sports physical therapy. 2003 Nov;33(11):671-6
  2. 2.0 2.1 Sadler S, Cassidy S, Peterson B, Spink M, Chuter V. Gluteus medius muscle function in people with and without low back pain: a systematic review. BMC musculoskeletal disorders. 2019 Dec;20(1):1-7
  3. Crossley KM, van Middelkoop M, Barton CJ, Culvenor AG. Rethinking patellofemoral pain: prevention, management and long-term consequences. Best Practice & Research Clinical Rheumatology. 2019 Feb 1;33(1):48-65.
  4. Uritani D, Kasza J, Campbell PK, Metcalf B, Egerton T. The association between psychological characteristics and physical activity levels in people with knee osteoarthritis: a cross-sectional analysis. BMC musculoskeletal disorders. 2020 Dec;21(1):1-7
  5. Lee TQ, Anzel SH, Bennett KA, Pang D, Kim WC. The influence of fixed rotational deformities of the femur on the patellofemoral contact pressures in human cadaver knees. Clinical orthopaedics and related research. 1994 May 1(302):69-74
  6. Moore D, Semciw AI, Pizzari T. A systematic review and meta-analysis of common therapeutic exercises that generate highest muscle activity in the gluteus medius and gluteus minimus segments. International Journal of Sports Physical Therapy. 2020 Dec;15(6):856.
  7. Preece SJ, Graham-Smith P, Nester CJ, Howard D, Hermens H, Herrington L, Bowker P. The influence of gluteus maximus on transverse plane tibial rotation. Gait & posture. 2008 May 1;27(4):616-21.
  8. Richard W. Willy, John P. Scholz, Irene S. Davis. Mirror gait retraining for the treatment of patellofemoral pain in female runners. Clinical Biomechanics 2012; 27: 1045-1051.
  9. 9.0 9.1 Robertson, C. Gluteal Considerations in the Management of Patellofemoral Pain. Course. Physioplus. 2022.
  10. Bramah C, Preece SJ, Gill N, Herrington L. Is there a pathological gait associated with common soft tissue running injuries?. The American journal of sports medicine. 2018 Oct;46(12):3023-31.
  11. Enhance RunningEnhance running: excessive hip adduction & internal rotation. Available from https://www.youtube.com/watch?v=QTC9hEu0pQQ&t=2s Accessed on 05/06/2022
  12. 12.0 12.1 De Bleecker C, Vermeulen S, De Blaiser C, Willems T, De Ridder R, Roosen P. Relationship between jump-landing kinematics and lower extremity overuse injuries in physically active populations: a systematic review and meta-analysis. Sports Medicine. 2020 Aug;50(8):1515-32.
  13. Neamatallah Z, Herrington L, Jones R. An investigation into the role of gluteal muscle strength and EMG activity in controlling HIP and knee motion during landing tasks. Physical Therapy in Sport. 2020 May 1;43:230-5.
  14. Bullock-Saxton JE, Janda V, Bullock MI. Reflex activation of gluteal muscles in walking. An approach to restoration of muscle function for patients with low-back pain. Spine. 1993 May 1;18(6):704-8.
  15. Beckman SM, Buchanan TS. Ankle inversion injury and hypermobility: effect on hip and ankle muscle electromyography onset latency. Archives of physical medicine and rehabilitation. 1995 Dec 1;76(12):1138-43.